Robotic resection of the rectum - what are the advantages?

INTRODUCTION: Surgical treatment is the most important part of multimodal management of rectal cancer. In recent years, minimally invasive surgery has been preferred. Minimally invasive procedures include laparoscopy and more recently robotic surgery. Robotic surgery has been developed to eliminate the shortcomings of laparoscopy, especially the parallel position of instruments and their limited movement. The advantages of a robotic system should be most apparent in narrow and deep spaces, i.e. the lesser pelvis. The aim of this study was to analyze the short-term results of robot-assisted surgery for rectal tumors. METHODS: The study is a retrospective analysis of a cohort of 220 patients with robotic-assisted surgery for rectal cancer. The cohort was analyzed in terms of length of surgery, blood loss, number of conversions to open surgery, completeness of TME, distal and circumferential resection margin positivity, length of hospital stays and number of 30-day rehospitalizations. In addition, 30-day postoperative morbidity and mortality were assessed using the Clavien-Dindo score. RESULTS: Robotic-assisted surgeries lasted an average of 184 minutes. In total, 5 operations were converted, i.e. 2.3%. Complete mesorectum was achieved in 90% of the patients. Severe postoperative complications, Clavien-Dindo score 3-4, were observed in 14% of the patients. Anastomotic complications occurred in 9.6% of the patients. The mean length of the hospital stay was 8.4 days. CONCLUSION: Robotic surgery for rectal tumors is a safe method with an acceptable rate of complications. An established training method and a high degree of standardization of the surgical procedures are indisputable advantages of robotic systems, making it possible to achieve very good results in a short time. In terms of perioperative and early postoperative outcomes, robotic surgery outperforms laparoscopic surgery in some parameters.

Methodology for implementing early recovery after surgery protocols in colorectal surgery.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols in colorectal surgery leads to improved quality of care and more efficient resource utilization. Despite these positive outcomes, the penetration of ERAS protocols in the Czech Republic is low. The aim of this study is to present a general methodology for implementing an ERAS protocol in colorectal surgery. METHODS: The methodology is based on the authors' extensive experience in implementing clinical protocols at various institutions in the Czech Republic, as well as published international experiences. This methodology is described in detail and supplemented with data obtained during implementation of an ERAS program at the author's institution. RESULTS: The preparatory phase includes in-depth quality of care audits and preparation of an ERAS protocol. The purpose of the audits is to identify areas of care where standardization or targeted changes in clinical practice are desirable. The implementation phase involves staff training, technical implementation support, protocol dissemination, adherence monitoring, and evaluation of a pilot phase with subsequent protocol adjustments. The evaluation phase involves data collection, maintaining a prospective database, and regular assessments. CONCLUSION: The presented methodology describes the individual steps in the process of implementing a clinical protocol into practice. This text can serve as a manual for implementing an ERAS protocol in colorectal surgery at any institution.

Effect of neoadjuvant therapy on early postoperative complications in rectal cancer.

INTRODUCTION: The treatment of locally advanced rectal cancer is multimodal. It includes neoadjuvant chemoradiotherapy (NCHRT). NCHRT has been shown to reduce the risk of local recurrence. New treatment regimens also have a positive impact on patient survival. NCHRT leads to fibrotic changes in the pelvis and is associated with side effects. NCHRT may have a negative impact on postoperative complications. The aim of this study was to demonstrate whether NCHRT increases the number of early postoperative complications. METHODS: An analysis of our own cohort of 200 patients with rectal cancer undergoing robotic-assisted surgery between 2018 and 2022 was performed. The cohort was divided into patients who underwent NCHRT and subsequently surgery and patients who underwent primary surgery. The two groups were compared in terms of duration of surgery, blood loss, incidence of anastomotic complications, and quality of mesorectal excision. RESULTS: Patients who underwent NCHRT had a longer operation time, by 34 minutes on average. We did not demonstrate a higher incidence of anastomotic complications in these patients. Patients who underwent primary surgery had a slightly lower blood loss and better quality of mesorectal excision during surgery. Nevertheless, complete or nearly complete mesorectal anastomosis was achieved in more than 85% of cases in both groups. CONCLUSION: Radiotherapy results in postradiation changes in the lesser pelvis. These changes impair visibility and dissection during surgery. Operations after NCHRT are more technically demanding and take longer but do not have more anastomotic complications. Also, the quality of mesorectal excision is satisfactory in both groups.

Enhanced recovery after surgery and mini-invasive approaches in rectal cancer surgery - short-term outcomes.

INTRODUCTION: The aim of this study was to evaluate short-term outcomes of patients undergoing mini-invasive rectal resection within an ERAS (enhanced recovery after surgery) protocol. METHODS: A prospectively managed database of patients undergoing rectal operations performed at our department between January 2015 and April 2020 was retrospectively analyzed. An ERAS protocol was implemented into clinical practice at our department in April 2016 and mini-invasive rectal procedures in May 2016. The ERAS group consisted of all patients who underwent mini-invasive rectal resections or amputations within the ERAS protocol. The control group consisted of patients who underwent open procedures and received standard perioperative care. The extracted data included basic patient characteristics, surgical data, postoperative recovery parameters, 30-day morbidity, length of postoperative stay and 30-day rehospitalization. RESULTS: A total of 110 patients were included in the study: 67 patients in the ERAS group and 43 in the control group. Within the ERAS group 47 patients underwent robotic procedures and 20 had laparoscopic procedures. Patients in the ERAS group had significantly better clinical and laboratory recovery parameters except for postoperative nausea and vomiting. A significantly lower incidence of paralytic ileus (20.9% vs. 3%) and a shorter length of postoperative stay (13 days vs. 9 days) was found in the ERAS group. The rehospitalization rate and 30-day morbidity were not different between the ERAS and control group. CONCLUSIONS: Implementation of the ERAS protocol in combination with mini-invasive approaches leads to better short-term postoperative outcomes after rectal surgery.

Lymph nodes detection and the mesorectal excision quality evaluation.

INTRODUCTION: Detection and examination of proper number of lymph nodes in patients after rectal resection is important for next treatment and management of patients with rectal carcinoma. There are no clear guideliness for minimal count of lymph nodes, variant recommendations agree on the number of 12 (1014) nodes. There are situations, when is not easy to reach this count, mainly in older age groups and in patients after neoadjuvant, especially radiation therapy. As a modality for improvement of lymph nodes harvesting seems to be establishing of defined protocols originally designed for mesorectal excision quality evaluation. METHODS: The investigation group was formed by patients examined in 2 three-years intervals before and after implementation of the protocol. Elevation in count of harvested lymph nodes was rated generaly and in relation to age groups and gender. RESULTS: The average count of lymph nodes increased from 10 to 15 nodes, in subset of patients whose received neoadjuvant therapy from 7 to almost 14 nodes. The recommended number of lymph nodes was obtained in all investigated age groups. By the increased number of lymph nodes, rises also possibility of positive nodes found, that can lead to upstaging of the disease, in subset of patients whose received neoadjuvant therapy it is more than 4%. CONCLUSION: Our conclusions show, that forming of multidisciplinary cooperative groups (chiefly surgeon-pathologist), implementation of defined protocol of surgery, specimen manipulation and investigation by detached specialists lead to benefit consequences for further management and treatment of the patients with colorectal cancer.

Electrospun nanofibers as support for the healing of intestinal anastomoses.

The breakdown of intestinal anastomosis is a serious postsurgical complication. The worst complication is anastomotic leakage, resulting in contaminated peritoneal cavity, sepsis, multi-organ failure and even death. In problematic locations like the rectum, the leakage rate has not yet fallen below 10 %. Such a life-threatening condition is the result of impaired healing in the anastomotic wound. It is still vital to find innovative strategies and techniques in order to support regeneration of the anastomotic wound. This paper reviews the surgical techniques and biomaterials used, tested or published. Electrospun nanofibers are introduced as a novel and potential material in gastrointestinal surgery. Nanofibers possess several, unique, physical and chemical properties, that may effectively stimulate cell proliferation and collagen production; a key requirement for the healed intestinal wound.

[Parametric monitoring of the quality of total mesorectal excision and surgical treatment of rectal carcinoma results of a multicenter study]. / Parametrické sledování kvality totální mezorektální excize a chirurgické lécby karcinomu rekta výsledky multicentrické studie.

INTRODUCTION: Tumour size and the quality of its complete surgical removal are the main prognostic factors in rectal cancer treatment. The number of postoperative local recurrences depends on whether the mesorectum has been completely removed - total mesorectal excision (TME) - and whether tumour-free resection margins have been achieved. The surgery itself and its quality depend on the accuracy of preoperative diagnosis and detection of risk areas in the rectum and mesorectum, on the surgeons skills, and finally on pathological assessment evaluating whether complete tumour excision has been accomplished including circumferential margins of the tumour, and whether mesorectal excision is complete. The aim of our study was to implement and standardize a new method of evaluation of the quality of the surgical procedure - TME - in rectal cancer treatment using an assessment of its circumferential margins (CRO) and completeness of the excision. METHODS: The study consisted of two parts. The first, multi-centre retrospective phase with 288 patients analysed individual partial parameters of the diagnosis, operations and histological examinations of the rectal cancer. Critical points were identified and a unified follow-up protocol was prepared. In the second, prospective part of this study 600 patients were monitored parametrically focusing on the quality of the TME and its effect on the oncological treatment results. RESULTS: The proportion of patients with restaging following neoadjuvant therapy increased from 60.0% to 81.7% based on preoperative diagnosis. The number of specimens missing an assessment of the mesorectal excision quality decreased from 52.9% in the retrospective part of to the study to 22.8% in the prospective part. The proportion of actually complete TMEs rose from 22.6% to 26.0%, and that of nearly complete TMEs from 10.1% to 24.0%. CONCLUSION: The introduction of parametric monitoring into routine clinical practice improved the quality of pre-treatment and preoperative diagnosis, examination of the tissue specimen, and consequently improved quality of the surgical procedure was achieved. KEY WORDS: rectal cancer TME - parametric monitoring - quality control.